Spotlight on sub-Saharan Africa: A look at the impact of the epidemic on the women of sub-Saharan Africa

By Professor Courtney Sprague In 2006, UNAIDS estimated that 17.3 million women were living with HIV. Three quarters of those women (13.2 million) were living in sub-Saharan Africa (SSA). Today roughly 60% of all adults with HIV in sub-Saharan Africa are women (UNAIDS 2006). These figures must be set against some larger trends. The evidence base of health and development research demonstrates that there have been remarkable health achievements in the last 50 years. The ‘global health revolution’ has resulted in an additional four months of life expectancy added each calendar year over the last three decades for some countries – with significant reductions in

maternal mortality. More than 10 years have been added to women’s life expectancy in some countries as a result. But African women are not enjoying these health achievements. Instead, health outcomes in the continent reveal patterns of premature illness and death, largely attributed to HIV/AIDS (Jamison et al 2006; Doyal 2006; 2001; Médecins sans Frontières 2001; Chen and Berlinguer 2001).

Sub-Saharan African women of reproductive age are disproportionately affected by HIV, with women in younger age groups four times more likely to be HIV-infected than men. Women’s greater vulnerability to, and risk of, HIV acquisition is both biological and social. Biologically, women are more susceptible to contracting sexually transmitted infections (STIs) than men, including HIV, due to the greater area of mucous membrane exposed during sex (particularly young women whose genital tracts are not fully developed), the larger quantity of fluids that are transferred from men to women during sex, and the higher viral content in male sexual fluids. Micro-tears can also easily occur in women’s vaginal tissue as a result of sex. And, many SSA countries are believed to have a large number of untreated STIs. Individuals with untreated STIs are over six times more likely than other individuals to pass on or acquire HIV during sex: a genital sore caused by an STI increases the risk of becoming infected with HIV from a single exposure by 10 to 300 times (UNAIDS 2004a-b).   Through increasing mortality, morbidity and related impacts, the global HIV pandemic is illustrating the myriad ways in which gender inequalities impact negatively on African women’s health. Women’s unequal status and position in society is often at the centre of such health inequalities (Dunkle et al 2004). Sexual risk behaviour is associated with an inability to negotiate condom use, peer pressure to have sex, and ‘coercive’ male dominated relationships (Matthews 2005; Jewkes 2002; Klugman 2000). Studies have demonstrated that social context and position, as well as cultural factors and norms, have been significant in increasing HIV transmission among African women (Government of South Africa 2007; Jewkes, Penn-Kekana and Rose-Junius 2005). The position of women in sub-Saharan Africa means that they are often born into inequity; an inequity characterised by low socio-economic status, which predisposes women to poverty, to malnutrition and to lack of control over their own fertility. This restricts the range of protections women have from contracting STIs, including HIV (Ackermann and de Klerk 2002; Bernstein and Juul Hansen 2006; Sprague 2008). Ackermann and de Klerk and others observe that gender violence is widely understood to be a large problem, though the exact levels are not known. Rape is one of the least notified crimes (including child rape) (2002, p. 166). For example, in South Africa, only an estimated 2,8% of rapes are reported (Ramsay 1999). As the WHO states: “Gender-based violence is a major risk factor for the ill health and lack of wellbeing of girls and women around the world” (no date). A study conducted by researchers from the University of the Witwatersrand in South Africa is illustrative, indicating that more than 60% of women in South Africa were regularly battered by partners or spouses and 50%-60% of marriages were reported to involve physical and sexual violence (Wood, Jewkes and Maforah 1998). “Gender-based violence and gender inequality are increasingly cited as important determinants of women's HIV risk; yet empirical research on possible connections remains limited” emphasise Dunkle et al (2004).   Given the burden of HIV infection and the associated social impacts, the connections between gender, health and HIV cannot be dismissed (Gender Medicine 2006; Grown, Gupta and Pande 2005; Klugman 1999). Through research on access to and provision of healthcare and HIV treatment and prevention, what is becoming clear is this: an overlapping set of inequalities and disadvantage joins a cascade of missed opportunities for healthcare, HIV prevention and treatment. These factors, when combined, put women at further risk of ill health and premature morbidity and mortality, while greatly undermining their prospects for development. As HIV continues to take a toll on women in our societies, now is the time to interrupt this cycle of deprivation, inequality and ill health. There is no more important time. Courtenay Sprague is an Associate Professor at the Graduate School of Business Administration, University of the Witwatersrand in South Africa (Wits). Her recent research has focused on access to antiretroviral medicines (particularly for women and children), social determinants of health and health equity. She has conducted HIV-related training and education for UNAIDS and produced health and HIV research for the UNDP, Treatment Action Campaign, Human Rights Watch and USAID. Courtenay has a double MA in international relations and resource and environmental management from Boston University (USA); and a PhD in development studies from Wits University.  Sources: Ackermann, Leáne and Gerhardt de Klerk. 2002. Social Factors that Make South African Women Vulnerable to HIV Infection. Health Care for Women International 23: 163-172. Bernstein, Stan and Charlotte Juul Hansen. 2006. Public Choices, Private Decisions: Sexual and Reproductive Health and the Millennium Development Goals. New York: UNDP.  Chen, Lincoln and Giovanni Berlinguer. 2001. Health Equity in a Globalizing World. In: Evans et al, eds. Challenging Inequities to Health: From Ethics to Action. Oxford: Oxford University Press. Doyal, Leslie. 2006. How Well are Women Worldwide? Lancet 367 (June 10): 1893-1894. Doyal, Leslie. 2001. Sex, Gender and Health: the Need for a New Approach. British Medical Journal 323: 1061-1063. Doyal, Leslie. 2000. Gender Equity in Health: Debates and Dilemmas. Social Science & Medicine 51: 931-939.  Dunkle, K, Rachel Jewkes, H Brown, Glenda Gray, James McIntyre, and S Harlow. 2004. Gender-Based Violence, Relationship Power, and Risk of HIV Infection in Women Attending Antenatal Clinics in South Africa. Lancet 363:1415-21. Matthews, Catherine. 2005. Reducing Sexual Risk Behaviours: Theory and Research, Successes and Challenges. In: Salim Abdool Karim and Quarraisha Abdool Karim, eds. HIV/AIDS in South Africa. Cambridge: Cambridge University Press: 143-165. Gender Medicine. 2006. Gender-Specific Aspects of the Burden of HIV/AIDS in South Africa – Communicable Diseases. Gender Medicine 3 (Supplement 1): S22.  Government of South Africa. 2007. HIV & AIDS and STI Strategic Plan for South Africa (2007-2011). 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